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5002.ARM
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1991-06-27
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/* Arizona living will form*/
STATUTORY DECLARATION IN CONFORMANCE WITH ARIZONA
MEDICAL TREATMENT DECISION ACT, AZ. REV. STAT. 36-3202
DECLARATION OF @001
Declaration made this __________ day of ________________
19________. I ,@001, being of sound mind, willfully and
voluntarily make known my desires that my dying shall not be
artificially prolonged under the circumstances set forth below
and declare that:
If at any time I should have an incurable injury,
disease, or illness certified to be a terminal condition by
two physicians who have personally examined me, one of whom
is my attending physician, and the physicians have determined
that my death will occur unless life-sustaining procedures are
used and if the application of life-sustaining procedures would
serve only to artificially prolong the dying process, I direct
that such procedures be withheld or withdrawn, and that I be
permitted to die naturally with only the administration of
medication, food or fluids or the performance of any medical
procedures deemed necessary to provide me with comfort care.
In the absence of my ability to give directions
regarding the use of such life-sustaining procedures, it is
my intention that this declaration shall be honored by my
family and physicians as the final expression of my legal right
to refuse medical or surgical treatment and accept the
consequences from such refusal.
I understand the full import of this declaration and
I have the emotionally and mental capacity to make this
declaration.
________________________________________
@001
City of residence: @002
County of residence: @003
State of residence: @004
Date: ________________________________
The declarant has been personally known to me and
I believe him or her to be of sound mind.
Witness _________________________________________________
Witness _________________________________________________
Date: _________________________